Utilization Review Registered Nurse; UR RN

Utilization Review Registered Nurse (UR RN)

Wichita, United States

• Salary Competitive exempt salary based on experience, education, and qualifications.
• State/Province Kansas
• Country United States

Department: Integrated Health Management
Reports To: Integrated Health Management Supervisor/Manager
Clinical Oversight: Medical Director, as applicable
FLSA Status: Non-Exempt
Employment Status: Full-Time, Hourly

Salary: Based on previous work experience andyears of experience

• Perform prospective, concurrent,and retrospective utilization reviews.
• Review requests for inpatient and outpatient services, procedures, surgeries, diagnostic testing, therapies,durable medical equipment, specialty medications, and other services requiring utilization review or prior authorization.
• Review medical records and supporting clinical documentation to determine whether sufficient information is available to complete the review.
• Apply approved evidence-based clinical criteria consistently and appropriately.
• Evaluate diagnoses, treatment plans, previous treatments, laboratory findings, imaging results,physician documentation, medication history, and other relevant clinical information.
• Approve services that meet applicable clinical criteria and fall within delegated nursing authority.
• Refer cases that do not meet established criteria, involve clinical uncertainty, or may result in anadverse medical-necessity determination to the Medical Director or other qualified physician reviewer.
• Request additional clinical documentation from providers when necessary.
• Accurately document the clinical rationale and criteria used during the review.
• Complete reviews with inapplicable regulatory, contractual, plan-specific, and departmental turnaround-time requirements.

• Review authorization requests submitted before services are rendered.
• Determine whether adequate clinical documentation has been submitted to support the requested service.
• Determine whether requests qualify for routine or urgent/expedited processing according to applicable definitions.
• Review clinical justification submitted for urgent requests.
• Apply applicable medical-necessity criteria and utilization-management requirements.
• Evaluate requested level of care,site of service, frequency, duration, and other relevant clinical factors.
• Identify opportunities for clinically appropriate alternative sites of care when applicable.
• Request missing clinical documentation promptly to avoid unnecessary delays.
• Refer cases requiring physician-level clinical judgment to the Medical Director.

• Conduct concurrent review of inpatient admissions and other ongoing services requiring continued authorization.
• Evaluate continued medical necessity and appropriateness of the current level of care.
• Obtain clinical updates from hospitals, facilities, and providers.
• Monitor treatment progression,length of stay, discharge planning, and barriers to discharge.
• Identify opportunities for transition to a lower level of care when clinically appropriate.
• Refer members with complex discharge needs, significant medical conditions, or ongoing care-coordination needs to Case Management.
• Escalate cases involving potential reduction or termination of previously authorized services according to established procedures.
• Complete continued-stay reviews within required time frames.
• Conduct retrospective reviews when services were provided without prospective authorization or when retrospective review is otherwise appropriate.
• Evaluate clinical documentation based on the patient's clinical condition and information available at thetime services were rendered.
• Apply appropriate clinical criteria and plan provisions.
• Document findings and recommendations.
• Refer cases…